435202961-8-25-2025-26-AS-RMAO-DLASFR-20250907135046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202961
Report Date: 08/25/2025
Date Signed: 08/25/2025 01:20:53 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2025 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20250522101130

FACILITY NAME:	ELLORE SENIOR LIVING		FACILITY NUMBER:	435202961
ADMINISTRATOR:	AQUINO, JOYCE		FACILITY TYPE:	740
ADDRESS:	2350 CALLE DE LUNA		TELEPHONE:	(408) 755-6868
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY:	303	CENSUS: 27	DATE:	08/25/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Executive Director, Slyvia Chu		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility staff do not ensure the facility is free from pests.
Facility staff engaged in food preparation and services are not observing personal hygiene and food services.
Facility staff are not performing hand hygiene before and after resident care.
The number of residents assigned to staff scheduled is unbalanced resulting in staff not meeting the care needs of residents in memory care unit.
Facility staff left resident's undergarments soiled.
Residents' bedrooms were observed unkempt.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Slyvia Chu and stated the purpose of today’s visit.

On 5/22/2025, the Department received a complaint with the above allegations. On 5/30/2025, the Department conducted an initial investigation at the facility. On 6/23/2025, the Department conducted an additional investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 5.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 26-AS-20250522101130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELLORE SENIOR LIVING	FACILITY NUMBER: 435202961
	VISIT DATE: 08/25/2025

NARRATIVE

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Page 2 of 5.
Facility staff do not ensure the facility is free from pests.
It was alleged that the facility has an infestation of flying bugs.

On 5/30/2025, LPA Rai toured and inspected the facility to include the common areas, resident bedrooms and kitchen. LPA Rai did not observe flying bugs in the facility.

On 5/30/2025, LPA Rai interviewed 2 staff (S1-S2). S2 stated on 5/15/2025 there have been nats (flying bugs) observed in the building due to Santa Clara County not picking up the compost in the back of the building. S2 stated a third-party vendor, EcoLab was called into the facility to address the nats (flying bugs).

On 6/23/2025, LPA Rai interviewed 1 staff (S3). S3 stated the facility has a trash compacter inside the building and the nats will come if trash is not taken out daily. The facility has the city pick up trash weekly and a secondary trash service to pick up the other 6 days of the week.

Based on review of the EcoLab visit on 5/16/2025, there were no pest activity found in the facility and treatment was conducted in the facility.

Facility staff engaged in food preparation and services are not observing personal hygiene and food services.
It was alleged that there were half milk and almond milk left out in the lobby area.

On 5/30/2025, LPA Rai toured and inspected the facility to include the common areas, resident bedrooms and kitchen. LPA Rai did not observe milk in the lobby area. LPA Rai did observe small packs of creamer, which can be left room temperature.

On 5/30/2025, LPA Rai interviewed 2 staff (S1-S2). Two out of two staff stated they did not observe milk in the lobby area.

On 6/23/2025, LPA Rai interviewed 1 staff (S3). S3 stated there is no milk left in the lobby area.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20250522101130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELLORE SENIOR LIVING	FACILITY NUMBER: 435202961
	VISIT DATE: 08/25/2025

NARRATIVE

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Page 3 of 5.
Facility staff are not performing hand hygiene before and after resident care.

On 5/30/2025, LPA Rai toured and inspected the facility to include resident rooms while staff were performing resident care. LPA Rai observed 1 staff member wearing gloves while providing care to resident. LPA Rai observed the same staff member taking off the gloves and disposing the gloves in a trash can with lid after performing care to the resident.

On 5/30/2025, LPA Rai interviewed 2 staff (S1-S2). Two out of two staff stated the staff are aware and trained on hand hygiene. Two out of two staff stated they have not seen or heard of staff not using proper hand hygiene before and after resident care.

On 6/23/2025, LPA Rai interviewed 1 staff (S3). S3 stated the staff are trained in proper hand hygiene and S3 was able to verbally explain proper hand hygiene. S3 stated the facility has hand washing station near the elevator and in the main areas of the building.

Based on review of staff training at random, four out of four staff are trained in the following topics which include but not limited to “All About Personal Protective Equipment”, “Hand Hygiene Basics” and “Infection Control” Essential Principles”.

The number of residents assigned to staff scheduled is unbalanced resulting in staff not meeting the care needs of residents in memory care unit.

On 5/30/2025, LPA Rai toured and inspected the facility to include the common areas, resident bedrooms and kitchen. LPA Rai observed 2 residents and 2 staff in the memory care unit.

On 5/30/2025, LPA Rai interviewed 2 staff (S1-S2). Two out of two staff stated the staff to resident ratio has been 1:1 or sometimes 2 staff to 1 resident. S2 stated to have assigned the shifts if there needs to be additional assistance with the residents. S2 stated medication technicians will assist with caregiver duties as well to provide care and supervision to the residents.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20250522101130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELLORE SENIOR LIVING	FACILITY NUMBER: 435202961
	VISIT DATE: 08/25/2025

NARRATIVE

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Page 4 of 5.

On 6/23/2025, LPA Rai interviewed 1 staff (S3). S3 stated there have been 1:1 staff to resident ratio and now with the increase of census the ratio has been 1 staff to 2 residents.

Based on review of staff schedule for 05/11/2025 – 05/17/2025 in the memory care unit, every day (Sunday – Saturday) there is one assigned caregiver and one assigned medication technician for the morning shift and afternoon shift and two assigned caregivers for the night shift. On Sundays and Mondays, there is only 1 assigned medication technician for the afternoon shift and 1 assigned caregiver for the night shift.

Facility staff left resident’s undergarments soiled.
It was alleged in the memory care unit resident’s undergarments were left soiled during the night.

On 5/30/2025, LPA Rai interviewed 2 staff (S1-S2). Two out of two staff stated they did not see or heard of residents’ undergarments left soiled during the night. Two out of two staff stated they have not seen any notes made by the night care staff on issues of not providing care at night to the residents.

On 6/23/2025, LPA Rai interviewed 1 staff (S3). S3 stated they did not see or heard of residents’ undergarments left soiled during the night. S3 stated they have not seen any notes made by the night care staff on issues of not providing care at night to the residents.

Based on review of R1’s needs and services plan dated 4/30/2025, R1 has an indwelling urinary catheter and requires schedule for toileting and assistance to and from the bathroom; needs assistance with incontinent supplies, hygiene and/or changing linen. Based on review of R1’s bowel record and care provider night shift notes for the month of May 2025, R1 was assisted with toileting according to the schedule.

Based on review of R2’s needs and services plan dated 5/7/2025, R2 requires schedule for toileting and assistance to and from the bathroom; needs assistance with incontinent supplies, hygiene and/or changing linen. Based on review of R2’s bowel record and care provider night shift notes for the month of May, R2 was assisted with toileting according to the schedule.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20250522101130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELLORE SENIOR LIVING	FACILITY NUMBER: 435202961
	VISIT DATE: 08/25/2025

NARRATIVE

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Page 5 of 5.
Residents’ bedrooms were observed unkempt.

On 5/30/2025, LPA Rai toured and inspected the facility to include resident bedrooms. LPA Rai observed 2 rooms that were occupied and 2 out of 2 resident rooms were clean and kempt?

On 5/30/2025, LPA Rai interviewed 2 staff (S1-S2). Two out of two staff stated the staff have been cleaning the resident rooms as well as the housekeeping staff. Two out of two staff stated there have been no issues with cleaning the residents’ rooms.

On 5/30/2025, LPA Rai attempted to interview 2 residents (R1-R2), but residents refused to answer questions.

On 6/23/2025, LPA Rai interviewed 1 staff (S3). S3 the staff have been cleaning the resident rooms as well as the housekeeping staff and there have been no issues with cleaning the residents’ rooms.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Slyvia Chu and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

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